Provider Demographics
NPI:1669713947
Name:EDDY, PAUL NELSON
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:NELSON
Last Name:EDDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25410 E STATE ROUTE EE
Mailing Address - Street 2:
Mailing Address - City:HARRISONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64701-4403
Mailing Address - Country:US
Mailing Address - Phone:816-260-2924
Mailing Address - Fax:816-884-4703
Practice Address - Street 1:25410 E STATE ROUTE EE
Practice Address - Street 2:
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701-4403
Practice Address - Country:US
Practice Address - Phone:816-260-2924
Practice Address - Fax:816-884-4703
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOLC1066421171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor